22.2 Survey

OMB #: 0925-0593

OMB Expiration Date: 07/31/2013

12-Month Mother SAQ, Phase 2e

12-Month Mother SAQ

Event:	12-Month
Participant:	Mother
Domain:	Questionnaire
Type of Document:	Self-Administered Questionnaire
Allowable Mode:	PAPI
Allowable Method:	In-Person, Mail
Recruitment Groups:	EH, PB, HI, PBS
Version:	3.0
Release:	MDES 3.0

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12-Month Mother SAQ

TABLE OF CONTENTS

12-MONTH MOTHER SAQ INSTRUMENT (EH, PB, HI) SELF-ADMINISTERED QUESTIONNAIRE 1

12-Month Mother SAQ

NOTE: THE SAQS MAY BE COMPLETED IN EITHER A PAPI OR CASI MODE

INTERVIEWER INSTRUCTION:

• IF COMPLETED AS A PAPI, ENTER THE CHILD’S PARTICIPANT ID AND THE MOTHER’S PARTICIPANT ID ON THE INSTRUMENT.

(TIME_STAMP_1) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP.

IN001. Thank you for agreeing to participate in the National Children’s Study. This self-administered questionnaire will take about 10 minutes to complete. There are questions about your relationships, experiences as a parent, and questions about your child’s diet.

Your answers are important to us. There are no right or wrong answers. You can skip over any question. We will keep everything that you tell us confidential.

PROGRAMMER INSTRUCTIONs:

• IF RESP_REL =1 AND

  • MARISTAT IN PERSON TABLE ≠ 1 OR 2, GO TO HAVE_PARTNER.

  • MARISTAT IN PERSON TABLE = 1 OR 2, GO TO RSC001A.

• OTHERWISE, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING SP_LONELY.

RSC001/(HAVE_PARTNER): Do you have a partner who you don’t live with?

Yes 1

No 2 (CFQ001)

REFUSED -1 (CFQ001)

DON’T KNOW -2 (CFQ001)

RSC001A. The first set of items are about your relationship with your spouse or partner. Please indicate the extent to which you agree or disagree with each statement.

RSC002/(SP_LISTEN). My spouse/partner listens to me when I need someone to talk to.

Strongly disagree 1

Somewhat disagree 2

Neither agree nor disagree 3

Somewhat agree 4

Strongly agree 5

REFUSED -1

DON’T KNOW -2

RSC003/(SP_FEEL). I can state my feelings without him getting defensive.

Strongly disagree 1

Somewhat disagree 2

Neither agree nor disagree 3

Somewhat agree 4

Strongly agree 5

REFUSED -1

DON’T KNOW -2

RSC004/(SP_DISTANT). I often feel distant from my spouse/partner.

Strongly disagree 1

Somewhat disagree 2

Neither agree nor disagree 3

Somewhat agree 4

Strongly agree 5

REFUSED -1

DON’T KNOW -2

RSC005/(SP_UNDERSTAND). My spouse/partner can really understand my hurts and joys.

Strongly disagree 1

Somewhat disagree 2

Neither agree nor disagree 3

Somewhat agree 4

Strongly agree 5

REFUSED -1

DON’T KNOW -2

RSC006/(SP_NEGLECT). I feel neglected at times by my spouse/partner.

Strongly disagree 1

Somewhat disagree 2

Neither agree nor disagree 3

Somewhat agree 4

Strongly agree 5

REFUSED -1

DON’T KNOW -2

RSC007/(SP_LONELY). I sometimes feel lonely when we’re together.

Strongly disagree 1

Somewhat disagree 2

Neither agree nor disagree 3

Somewhat agree 4

Strongly agree 5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF MULT_CHILD = 1 FOR 12-MONTH INTERVIEW, LOOP THROUGH QUESTIONNAIRE STARTING AT CFQ001 AND GO THROUGH HERBAL FOR EACH CHILD UNTIL CHILD_NUM = CHILD_QNUM.

• THEN GO TO TIME_STAMP_2.

CFQ001. The next questions will ask about the milk, formula, and food your child has eaten. In the past 7 days, how often was your baby fed each item listed below?

PARTICIPANT INSTRUCTIONS:

• Include feedings by everyone who feeds the baby and include snacks and night-time feedings.

• If your baby was fed the item once a day or more, write the number of feedings per day in the space above number and then circle “1” for “Day” below.

• If your baby was fed the item less than once a day, write the number of feedings per week in the spaces above number and then circle “2” for “Week” below.

• If your baby was not fed the item at all during the past 7 days, write “00” in the spaces above number

CFQ001A/(BREAST_MILK/BREAST_UNIT). In the past 7 days, how often was your baby fed breast milk (include breast fed and expressed or pumped breast milk)?

|___|___|

Number

REFUSED -1

DON’T KNOW -2

Day 1

Week 2

CFQ001B/(FORMULA/FORMULA_UNIT). In the past 7 days, how often was your baby fed formula?

|___|___|

Number

REFUSED -1

DON’T KNOW -2

Day 1

Week 2

CFQ001C/(COW_MILK/COW_MILK_UNIT). In the past 7 days, how often was your baby fed cow’s milk?

|___|___|

Number

REFUSED -1

DON’T KNOW -2

Day 1

Week 2

CFQ001D/(MILK_OTHER/MILK_OTHER_UNIT). In the past 7 days, how often was your baby fed other milk (soy milk, rice milk, goat milk)?

|___|___|

Number

REFUSED -1

DON’T KNOW -2

Day 1

Week 2

CFQ003/(BREAST_MILK_FED). Please tell me which best describes what your baby has been fed. My baby…

…is not drinking breast milk now, but was fed breast milk
in the past 1

…is drinking breast milk now 2 (PUMPED)

…was never fed breast milk 3 (FORMULA_FED)

REFUSED -1

DON’T KNOW -2

CFQ005/(BREAST_STOP)/(BREAST_STOP_UNIT). How old was your baby when you completely stopped breastfeeding and pumping or expressing breast milk?

PARTICIPANT INSTRUCTIONS:

• If baby was less than one month, enter age in weeks;

• If baby was older than one month, enter age in months.

|___|___|

Number

REFUSED -1

DON’T KNOW -2

Weeks 1

Months 2

CFQ007/(PUMPED). Have you ever fed your baby pumped or expressed breast milk?

Yes 1

No 2 (FORMULA_FED)

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF BREAST_MILK_FED = 1 OR -1 OR -2, GO TO FORMULA_FED.

• OTHERWISE, GO TO PUMPED_2.

CFQ009/(PUMPED_2). In the past 7 days, about how often was your baby fed pumped or expressed breast milk? Include feedings by everyone who feeds the baby and include snacks and nighttime feedings.

1 time per week 1

2 to 4 times per week 2

Nearly every day 3

1 time per day 4

2 to 3 times per day 5

4 to 6 times per day 6

More than 6 times per day 7

Not applicable/I have not fed my baby breast milk in the past 7 days -7

REFUSED -1

DON’T KNOW -2

CFQ011/(FORMULA_FED). How old was your baby when (he/she) was first fed formula on a daily basis?

Less than 1 month old 1

1 to 2 months old 2

3 to 4 months old 3

5 to 6 months old 4

More than 6 months old 5

Not applicable (never fed formula to baby) -7

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF FORMULA = 0 AND/OR FORMULA_FED = -7, GO TO BOTTLE_TYPE.

• IF FORMULA ≥ 1, GO TO FORMULA_BRAND.

• OTHERWISE, IF FORMULA = -1 OR -2, GO TO FORMULA_LAST7.

CFQ013/(FORMULA_LAST7). Has your baby had formula in the last seven days?

Yes 1

No 2 (BOTTLE_TYPE)

Not applicable (Never fed formula to baby) -7 (BOTTLE_TYPE)

REFUSED -1

DON’T KNOW -2

CFQ015/(FORMULA_BRAND). What kind of infant formula was your baby fed in the past 7 days?

PARTICIPANT INSTRUCTIONS:

• Select all that apply.

• Include any formula the baby was fed in the past 7 days that is not included on the list under “Other”.

Baby’s Only Organic Dairy 1

Baby’s Only Organic Soy 2

Baby’s Only Organic Lactose Free 3

Bright Beginnings milk-based 4

Bright Beginnings Gentle milk-based 5

Bright Beginnings Organic 6

Bright Beginnings milk-based 2 7

Bright Beginnings NeoCare 8

Earth’s Best Organic Infant Formula with DHA & ARA 9

Earth’s Best Organic Soy Infant Formula with DHA & ARA 10

EleCare® 11

Enfamil® Premium with Triple Health Guard 12

Enfamil® Premium Next Step 13

Enfamil® ProSobee® 14

Enfamil® RestFull 15

Enfamil AR® 16

Enfamil® Gentlease® 17

Enfamil® Gentlease® Next Step 18

Enfamil® Enfacare 19

Enfamil® Premature 20

Enfamil® Premium Vanilla or Chocolate 21

Enfamil® Soy Next Step 22

Gerber® Good Start® Gentle Plus 23

Gerber® Good Start® Gentle Plus 2 24

Gerber® Good Start® Protect Plus 25

Gerber® Good Start® Protect Plus 2 26

Gerber® Good Start® Soy Plus 27

Gerber® Good Start® Soy Plus 2 28

Nutramigen® with Enflora LGG 29

Nutramigen® AA 30

Pregestimil® 31

Similac® Advance® EarlyShield 32

Similac Isomil® Advance® 33

Similac Isomil® DF 34

Similac® Organic 35

Similac® Go & Grow 36

Similac® Go & Grow EarlyShield 37

Similac® Sensitive 38

Similac® Sensitive R.S. 39

Similac® Alimentum® 40

Similac® Neosure® 41

Store brand Milk based

(like Member’s Mark, Kirkland, Target up & up) 42

Store brand Gentle or partially broken down whey protein formula

(like Member’s Mark or Target up & up)) 43

Store brand Soy based (like Target up & up) 44

Store brand Next step (like Target up & up) 45

Store brand Lacto sensitive (like Target up & up) 46

Store brand Prebiotic (like Target up & up) 47

Other -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• DISPLAY INFANT FORMULAS ALPHABETICALLY.

• IF FORMULA_BRAND IS ANY COMBINATION OF 1 THROUGH 47, GO TO FORMULA_TYPE.

• IF FORMULA_BRAND = -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO FORMULA_TYPE.

• IF FORMULA_BRAND IS ANY COMBINATION OF 1 THROUGH 47, AND -5, GO TO FORMULA_BRAND_OTH.

• IF FORMULA_BRAND = -5, GO TO FORMULA_BRAND_OTH.

CFQ015/A(FORMULA_BRAND_OTH)

Specify: _________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT MAXIMIMUM LENGTH TO 255 CHARACTERS.

CFQ017/(FORMULA_TYPE). Was the formula ready-to-feed, liquid concentrate, powder from a can that makes a single serving, or powder from single serving packets?

PARTICIPANT INSTRUCTION:

• Select all that apply.

Ready-to-feed 1

Liquid concentrate 2

Powder from a can that makes more than one bottle 3

Powder from single serving packets 4

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF FORMULA_TYPE ONLY EQUALS 1, GO TO OUNCES.

• IF FORMULA_TYPE = 2 AND/OR 3 AND/OR 4 WITH OR WTHOUT 1, GO TO WATER_1.

• IF FORMULA_TYPE = -1 OR -2, GO TO BOTTLE_TYPE.

CFQ019/(WATER_1). During the past 7 days, what types of water have you and others who care for your baby used for mixing your baby’s formula?

PARTICIPANT INSTRUCTION:

• Select all that apply.

Tap water from the cold faucet 1

Warm tap water from the hot faucet 2

Bottled water 3

Other type of water used -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF WATER_1 = ANY COMBINATION OF 1 THROUGH 3, GO TO WATER_2.

• IF WATER_1 = -1 OR -2, DO NOT ACCEPT ANY OTHER RESPONSES, AND GO TO WATER_2.

• IF WATER_1 = ANY COMBINATION OF 1 THROUGH 3, AND -5, GO TO WATER_1_OTH.

• IF WATER_1 = -5, GO TO WATER_1_OTH.

CFQ020/(WATER_1_OTH).

Specify: _______________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT MAXIMIMUM LENGTH TO 255 CHARACTERS.

CFQ021/(WATER_2). Was the water used to mix the formula boiled?

Yes 1

No 2

REFUSED -1

DON’T KNOW -2

CFQ023/(OUNCES). In the past 7 days, on the average, how many ounces of formula did your baby drink at each feeding?

|__|__| Ounces

REFUSED -1

DON’T KNOW -2

CFQ025/(BOTTLE_TYPE). In the past 7 days, about how often did your baby drink from each of the following types of bottles and cups?

PROGRAMMER INSTRUCTION:

• DISPLAY ABOVE INTRODUCTORY STATEMENT FOR B_TYPE_1, B_TYPE_2, B_TYPE_3, B_TYPE_4, & B_TYPE_5.

CFQ025A/(B_TYPE_1). Plastic baby bottle with disposable bottle liner.

Never 1

Sometimes 2

Most of the Time 3

Always 4

REFUSED -1

DON’T KNOW -2

CFQ025B/(B_TYPE_2). Plastic baby bottle without disposable liner.

Never 1

Sometimes 2

Most of the Time 3

Always 4

REFUSED -1

DON’T KNOW -2

CFQ025C/(B_TYPE_3). Other plastic bottle (for example, a water bottle).

Never 1

Sometimes 2

Most of the Time 3

Always 4

REFUSED -1

DON’T KNOW -2

CFQ025D/(B_TYPE_4). Glass baby bottle.

Never 1

Sometimes 2

Most of the Time 3

Always 4

REFUSED -1

DON’T KNOW -2

CFQ025E/(B_TYPE_5). Plastic “no spill” cup.

Never 1

Sometimes 2

Most of the Time 3

Always 4

REFUSED -1

DON’T KNOW -2

CFQ027/(PACIFIER). Has your baby used a pacifier in the past 7 days?

Yes 1

No 2

REFUSED -1

DON’T KNOW -2

CFQ029/(COWS_MILK_1). Has your baby ever been fed cow’s milk that was not sold especially for babies? (This includes whole, low-fat, nonfat, or chocolate milk.)

Yes 1

No 2 (CEREAL)

REFUSED -1 (CEREAL)

DON’T KNOW -2 (CEREAL)

CFQ031/(COWS_MILK_2). How old was your baby when he/she was first fed cow’s milk that was not sold especially for babies?

|__|__|.|__| Age in months

REFUSED -1

DON’T KNOW -2

CFQ033/(CEREAL). How old was your baby when he/she was first fed cereal, including baby cereal, on a daily basis?

Less than 1 month old 1

1 to 2 months old 2

3 to 4 months old 3

5 to 6 months old 4

More than 6 months old 5

Not applicable (never fed cereal) -7

REFUSED -1

DON’T KNOW -2

CFQ035/(PUREED). How old was your baby when he/she was first fed pureed baby food on a daily basis? Please include commercial (store bought) and homemade baby food.

Less than 1 month old 1

1 to 2 months old 2

3 to 4 months old 3

5 to 6 months old 4

More than 6 months old 5

Not applicable (never fed

pureed baby food) -7

REFUSED -1

DON’T KNOW -2

CFQ037/(TABLE_FOOD). How old was your baby when he/she was first fed table food such as eggs, cheese, or potatoes on a daily basis?

Less than 1 month old 1

1 to 2 months old 2

3 to 4 months old 3

5 to 6 months old 4

More than 6 months old 5

Not applicable (never fed table food) -7

REFUSED -1

DON’T KNOW -2

CFQ039/(SUPPLEMENT). Which of the following supplements was your child given at least 3 days a week during the past 2 weeks?

PARTICIPANT INSTRUCTION:

• Select all that apply.

Fluoride 1

Iron 2

Vitamin D 3

Other vitamins or supplements: -5

Not applicable (child not given supplements) -7

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF SUPPLEMENT = ANY COMBINATION OF 1 THROUGH 3, GO TO HERBAL.

• IF SUPPLEMENT =-7, -1 OR -2, DO NOT ACCEPT ANY OTHER RESPONSES, AND, GO TO HERBAL.

• IF SUPPLEMENT = ANY COMBINATION OF 1 THROUGH 3, AND -5, GO TO SUPPLEMENT _OTH.

• IF SUPPLEMENT = -5, GO TO SUPPLEMENT _OTH.

CFQ040/(SUPPLEMENT_OTH)

Specify: _______________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT MAXIMIMUM LENGTH TO 255 CHARACTERS.

CFQ041/(HERBAL). Was your baby given any herbal or botanical preparations or any kind of tea or home remedy in the past 7 days? Do not count preparations put on the baby’s skin or anything the baby may have gotten from breast milk after you took an herbal or botanical preparation.

Yes 1

No 2

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_2) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

Thank you for participating in the National Children’s Study and for taking the time to complete this survey.

INTERVIEWER INSTRUCTION:

• IF SAQ IS COMPLETED AS A PAPI, SCs MUST PROVIDE INSTRUCTIONS AND A BUSINESS REPLY ENVELOPE FOR PARTICIPANT TO RETURN.

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.